Campaign Form - Dr Metuse

Apply for Pro Bono Surgery

Name

Age

Height

Weight

Date Of Birth

Residential Address

Contact

Email Address

Mecical Illnesses

Previous Deep Pulmonary Embolism

If Yes, Provide Details

Previous Deep Venous Thrombosis

If Yes, Provide Details

Current Medication

Contraceptives

If Yes, Provide Details

Allergies

If Yes, Provide Details

Previous Surgery

If Yes, Specify Year

Breast Cancer History

If Yes, Specify Relationship and Age of Person

History of Other Cancers

Are you a smoker?

Do you drink alcohol?

Could you share what led you to consider breast reduction surgery?

How have the physical or emotional aspects of your current breast size affected your daily life?

What are you most looking forward to after healing from this procedure?

Is there anything you’ve had to give up or avoid because of discomfort, and how do you imagine that changing after surgery?

How do you hope this surgery will help you feel more comfortable in your body?

Embrace the change; it's your journey to confidence.

Dr Nombulelo Metuse